Marley Warren & Lia J. Smith
March 24, 2026
LGBTQ individuals experience stressors related to their identity--including stigma, microaggressions, and violence--that increase their risk for the development of a variety of mental health concerns (e.g., Lu et al., 2025). One meta-analysis of 26 studies, for example, found that LGBTQ individuals had a significantly higher risk for every mental health category investigated (i.e., depression, alcohol use disorder, anxiety disorders, and suicidal ideation) relative to cisgender heterosexual individuals (Wittgens et al., 2022).
LGBT individuals may also be 1.36-4.51 times more likely to be diagnosed with PTSD relative to cisgender heterosexual individuals (Marchi et al., 2023). This discrepancy may be partially explained by the finding that, on average, LGBTQ individuals experience more potentially traumatic events over their lifetime than cisgender heterosexual individuals (Livingston et al., 2020; Roberts et al., 2010). This is especially true for interpersonal traumatic events, such as unwanted sex, domestic violence, kidnapping, or stalking (Ray et al., 2021; Roberts et al., 2010).
Evidence-based PTSD treatments among LGBTQ individuals
We conducted a systematic literature review focused on cognitive processing therapy (CPT), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR). These cognitive behavioral therapy-based, manualized psychotherapies for PTSD have historically been the most researched and consistently recommended across clinical practice guidelines. The most recent American Psychological Association (APA, 2025) treatment guidelines continue to highly recommend these three treatments, in addition to Trauma Focused Cognitive Behavioral Therapy (TF-CBT).
To the best of our knowledge, there is no scientific theory or model that predicts that these first-line treatments will be harmful or ineffective among LGBTQ individuals. It remains unclear, however, if these treatments are equally as effective among LGBTQ individuals relative to cisgender heterosexual individuals, especially given the unique set of stressors, greater PTSD severity, and higher rates of comorbid behavioral and mental health conditions often experienced by LGBTQ individuals (e.g., Livingston et al., 2020; Wittgens et al., 2022). Investigating whether these treatments are differentially efficacious could also clarify the need for LGBTQ-affirmative adaptations to these treatments.
Our systematic literature review investigated the proportion of peer-reviewed studies that reported sexual orientation and/or gender identity (SOGI) data beyond binary sex and/or gender, as well as the proportion of studies that reported enrolling any LGBTQ individuals. We systematically searched eight databases for randomized clinical trials that investigated the effect of CPT, PE, and/or EMDR on PTSD severity in adults. Included studies utilized standardized measures of PTSD and were written in English.
Main Findings
A total of 519 articles met all eligibility criteria. Only 10 out of these 519 articles (1.9%) reported participant SOGI information beyond binary sex and gender. These articles were published between 2012 and 2025, with five records focusing on CPT, three on EMDR, and two on PE. Each of these ten articles also reported enrolling at least one LGBTQ individual. Within these studies, 12.09% and 2.2% of participants identified as sexual- and gender-minorities, respectively. This roughly matches the prevalence of individuals who identified as sexual- (8.9%) and/or gender- (1.3%) minorities in a 2024 Gallup poll of U.S. adults (Jones, 2025).
Due to this small sample size and the inconsistent way SOGI data were reported in manuscripts, we were unable to compare the efficacy of treatments between LGBTQ individuals and cisgender heterosexual individuals.
Clinical and Public Health Implications
The relative efficacy of first-line PTSD psychotherapies among LGBTQ individuals remains understudied, as does the need for affirmative modifications to these treatments. This is in line with findings from other systematic reviews of treatment trials for depression and anxiety disorders (e.g., Heck et al., 2017). Until more information is available, we recommend that clinicians continue to follow the most recent clinical practice guidelines, which recommend manualized psychotherapies including CPT, PE, EMDR, and TF-CBT (APA, 2025). We also recommend that clinicians read Livingston and colleagues' (2020) clinical guidance article on PTSD treatments among LGBTQ populations, which suggests ways to incorporate examples of LGBTQ minority stressors into sessions and discusses considerations for comorbid conditions.
This systematic review is the first to identify that just 1.9% of RCTs for first-line PTSD treatments support SOGI data beyond binary sex and/or gender. This result highlights the need for improved reporting of full SOGI data--including reporting sex, gender, and sexual orientation identities separately, clarifying how SOGI variables were coded, and clarifying how SOGI variables were controlled for in models. With improved reporting of these variables, future research may be able to evaluate the effectiveness of trial outcomes within vulnerable and at-risk LGBTQ subgroups.
Discussion Questions
- Do you believe that LGBTQ-affirmative adaptations for first-line PTSD psychotherapies are necessary? Could affirmative adaptations enhance the efficacy of these treatments? Why?
- What might be some hesitations or objections to collecting and reporting full SOGI information beyond binary sex and gender among researchers? How would you respond to those challenges?
- What might be the potential benefits of reporting SOGI information beyond binary sex and gender, even when no LGBTQ individuals are enrolled in a study?
About the Authors
Marley Warren is a post-baccalaureate Clinical Research Coordinator at the Road Home Program at Rush University Medical Center, Chicago, IL. Marley’s research focuses on minority stress and trauma among LGBTQ individuals. Marley can be reached at: marley_warren@rush.edu.
Lia Smith, Ph.D. is a post-doctoral research fellow with Rush University Medical Center and the University of Chicago in Chicago, IL. Her work is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (TL1TR002388). Dr. Smith can be reached at lia_smith@rush.edu.
Reference Article
Warren, M., Smith, L.J., Pridgen, S.A., & Held, P. (2025). Inclusion of sexual- and gender-minoritized individuals in randomized clinical trials of first-line treatments for posttraumatic stress disorder: A systematic literature review. Journal of Traumatic Stress, 1–14. https://doi.org/10.1002/jts.70043
References
American Psychological Association (2025). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. https://www.apa.org/ptsd-guideline/ptsd.pdf
Heck, N. C., Mirabito, L. A., LeMaire, K., Livingston, N. A., & Flentje, A. (2017). Omitted data in randomized controlled trials for anxiety and depression: A systematic review of the inclusion of sexual orientation and gender identity. Journal of Consulting and Clinical Psychology, 85(1), 72–76. https://doi.org/10.1037/ccp0000123
Jones, J. M. (2025, February 20). LGBTQ+ identification in U.S. rises to 9.3%. Gallup. https://news.gallup.com/poll/656708/lgbtq-identification-rises.aspx
Livingston, N. A., Berke, D., Scholl, J., Ruben, M., & Shipherd, J. C. (2020). Addressing diversity in PTSD treatment: Clinical considerations and guidance for the treatment of PTSD in LGBTQ populations. Current Treatment Options in Psychiatry, 7(2), 53–69. https://doi.org/10.1007/s40501-020-00204-0
Lu, J. A., Soltani, S., Austin, S. B., Rehkopf, D. H., Lunn, M. R., & Langston, M. E. (2025). Mental health disparities by sexual orientation and gender identity in the All of Us research program. JAMA Network Open, 8(1), Article e2456264. https://doi.org/10.1001/jamanetworkopen.2024.56264
Marchi, M., Travascio, A., Uberti, D., De Micheli, E., Grenzi, P., Arcolin, E., Pingani, L., Ferrari, S., & Galeazzi, G. M. (2023). Post-traumatic stress disorder among LGBTQ people: A systematic review and meta-analysis. Epidemiology and Psychiatric Sciences, 32, Article e44. https://doi.org/10.1017/S2045796023000586
Ray, T. N., Lanni, D. J., Parkhill, M. R., Duong, T.-V., Pickett, S. M., & Burgess-Proctor, A. K. (2021). Interpersonal violence victimization among youth entering college: A preliminary analysis examining the differences between LGBTQ and non-LGBTQ youth. Violence and Gender, 8(2), 67–73. https://doi.org/10.1089/vio.2020.0076
Roberts, A. L., Austin, S. B., Corliss, H. L., Vandermorris, A. K., & Koenen, K. C. (2010). Pervasive trauma exposure among US sexual orientation minority adults and risk of posttraumatic stress disorder. American Journal of Public Health, 100(12), 2433–2441. https://doi.org/10.2105/AJPH.2009.168971
Wittgens, C., Fischer, M. M., Buspavanich, P., Theobald, S., Schweizer, K., & Trautmann, S. (2022). Mental health in people with minority sexual orientations: A meta‐analysis of population‐based studies. Acta Psychiatrica Scandinavica, 145(4), 357–372. https://doi.org/10.1111/acps.13405